Saint Mary Home

In the surveyor’s words

From the most serious findings on record at Saint Mary Home, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 16, 2022

  Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #60) reviewed for hospitalization , the facility failed to ensure medications were accurately reconciled after the resident returned from the hospital resulting in the omission of a medication for 9 days which resulted in a significant change in the residents mental status and a subsequent 12 day hospitalization . The findings include: Resident #60's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, written by MD #3 (resident's primary care physician) dated 10/13/20 identified Resident #60 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF755Aug 10, 2026

  Based on staff interview, observations, review of the facility medication storage, review of facility documentation and facility policy/procedures, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to ensure accurate reconciliation and the facility failed to ensure that an account of all controlled drugs is maintained and periodically reconciled. The findings include: Interview with the ADNS on 8/10/26 at 11:05 AM identified when the controlled substances are received into the facility, they are counted and signed by two nurses and placed on the appropriate medication cart. […]

• No harm, potential for more than minimal, widespreadF812Aug 10, 2026

  Based on observations, review of facility documentation and staff interviews, the facility failed to ensure kitchen staff wore beard guards and appropriately placed hair restraints during the handling of food and beverage items. The findings include: a. On 8/5/2026 at 12:24 PM, an observation of the tray line was made with the Assistant Director of Dietary. Dietary Aide #1 was observed filling coffee cups. Dietary Aide #1 had a beard and mustache without a beard guard.b. Dietary Aide #2 was observed working on the tray line in the facility's kitchen. Dietary Aide #2 was plating food from the steam table onto plates and then passing the completed plates to other staff. […]

• No harm, potential for more than minimal, widespreadF814Aug 10, 2026

  Based on observation of the dumpster area and staff interviews, the facility failed to ensure appropriate disposal of garbage and refuse. The findings include: On 8/3/2026 at 10: 46 AM, an observation of the dumpster and dumpster area with the Director of Dietary identified that waste materials were not confined to the dumpster and were present on the ground, concrete, and surrounding wall.The concrete slab and ground surrounding the dumpster had scattered food-related debris, including disposable food packaging such as single-serve milk, pudding, butter, and creamer containers. There was also some visible food waste, such as a leftover carrot and a full mustard packet. […]

• No harm, potential for more than minimal, widespreadF880Aug 10, 2026

  Number of residents sampled: see list of residentsNumber of residents cited: see list of residentsObserved poor practice on 6 of 7 units Based on review of the facility infection control program, observations, review of the clinical records, review of facility documentation, facility policy/procedures and interviews, the facility failed to ensure gloves were used appropriately and hand hygiene was performed to prevent the spread of infection and failed to ensure collected specimens were not stored together and placed on top a cart containing clean supplies. […]